YMCA of Calhoun County

After school Registration Form

2011-2012

Name: Age: Birth date: __

Please circle: Female/Male Grade ______

Address______

City______St______Zip______

HOME WORK

Mother’s Name______Phone ______Phone ______

Father’s Name______Phone ______Phone______

Father’s Cell Phone______Mother’s Cell Phone______

Doctor’s NamePhone #

Address______

Ins.Company______

Ins. Policy # ______

Emergency Contact: ______Phone #______

Allergies/Medical______

______

School—(Circle)

Alexandria Donoho Pleasant Valley White Plains

YMCA of Calhoun County

Authorize Pick-Up Form

Afterschool Child Care

Persons Authorized to Pick-Up—Phone #

1______2______

#______#______

3______4______

#______#______

5______6______

#______#______

7______8______

#______#______

Children will not be allowed to leave the premises without being signed out by an authorized parent/ legal guardian or designated adult. The child will be released ONLY to the listed names authorized above. A copy of a photo ID of the authorized person must accompany the authorization and IDs will be checked before child will be released. The pick up authorization must be signed by the parent/guardian prior to authorize pickup. Telephone authorization is not acceptable.

The YMCA staff will question those with whom it is unfamiliar and check their authorization as well as ask for proper identification.

Should this information change, the parent must complete an updated authorization form by coming to the YMCA or provide the YMCA Kitty Stone after school site director the proper documents at least twenty four hours prior to the child being picked up.

As a parent/guardian, I authorize my child to attend the YMCA Afterschool. In case of an emergency, the YMCA staff has my permission to give First-Aide or take my child to a physician for treatment. I give my permission to the YMCA staff to call a doctor for medical or surgical care if an emergency arise, I understand that a conscientious effort will be made to locate us,

I understand this expense and accept it as my responsibility.

I also consent to photography of my child for promotional YMCA Material.

______

Parents Signature Date

YMCA of Calhoun County